Provider Demographics
NPI:1346843612
Name:THANNICKAL, SUJA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SUJA
Middle Name:
Last Name:THANNICKAL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 S KINDERKAMACK RD
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-2166
Mailing Address - Country:US
Mailing Address - Phone:201-930-9010
Mailing Address - Fax:
Practice Address - Street 1:20 S KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-2166
Practice Address - Country:US
Practice Address - Phone:201-930-9010
Practice Address - Fax:201-802-1891
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02242300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist